Occupational social class, coping responses and infertility-related stress of women undergoing infertility treatment

Transcription

1 PATIENT EXPERIENCES Occupational social class, coping responses and infertility-related stress of women undergoing infertility treatment Katerina Lykeridou, Kleanthi Gourounti, Antigoni Sarantaki, Dimitrios Loutradis, Grigorios Vaslamatzis and Anna Deltsidou Aim and objectives. The aims of this study were to examine the association between (1) occupational social class and coping responses, (2) coping responses and infertility-related stress and (3) occupational social class and infertility-related distress. Background. The coping strategies that individuals use in most of the stressful situations vary according to certain factors, such as, the appraised characteristics of the stressful condition, personality dispositions and social resources. Design. This study was a cross-sectional survey. Methods. The study involved 404 women undergoing infertility treatment at a public clinic in Athens, Greece. State and trait anxiety (State-Trait Anxiety Inventory), infertility-related stress (Copenhagen Multi-centre Psychosocial Infertility) and coping strategies (Copenhagen Multi-centre Psychosocial Infertility) were measured. Results. Women of low/very low social class reported higher levels of active-confronting coping compared with women of higher social class (p < 0Æ001). A positive correlation between active-avoidance coping and both state and trait anxiety (r = 0Æ278 and 0Æ233, respectively, p < 0Æ01) was observed. The passive-avoidance coping scale was positively correlated with marital and personal stress (r = 0Æ186 and 0Æ146, respectively, p < 0Æ01). All three kinds of stress (marital, personal and social) were positively correlated with both active-avoidance (r = 0Æ302, 0Æ423 and 0Æ211, respectively, p < 0Æ01) and activeconfronting scale (r = 0Æ150, 0Æ211 and 0Æ141, respectively, p < 0Æ01). Conclusions. Infertile women of the lowest social class used more active-confronting coping and more passive-avoidance coping than women of the highest social class. Factors such as low social class and maladaptive coping strategies might contribute to infertility-related stress and anxiety. Relevance to clinical practice. Nurses and midwives who work in infertility clinics should aim to identify individuals who are at high risk for infertility stress and adjustment difficulties and they should minimise the identified risk factors for infertility-related stress and strengthen the protective factors. Key words: anxiety, coping strategies, psychological well-being, reproductive health, social class, stress Accepted for publication: 17 December 2010 Authors: Katerina Lykeridou, PhD, RM, RN, Professor in Midwifery, Department of Midwifery, Technological Educational Institute of Athens; Kleanthi Gourounti, PhDc, MMedSc, RM, Clinical Collaborator, Department of Midwifery, Technological Educational Institute of Athens, Elena Venizelou Hospital; Antigoni Sarantaki, MSc, RM, Lecturer, Department of Midwifery, Technological Educational Institute of Athens; Dimitrios Loutradis, PhD, Professor in Obstetrics and Gynecology, Alexandra Hospital, Medical School of University of Athens; Grigorios Vaslamatzis, PhD, Associate Professor of Psychiatrics, Medical School of University of Athens, Eginition Hospital; Anna Deltsidou, PhD, RM, RN, Associate Professor, Department of Midwifery, Technological Educational Institute of Athens, Athens, Greece Correspondence: Anna Deltsidou, Associate Professor, Department of Midwifery, Technological Educational Institute of Athens, Mitrodorou 24, 10441, Greece. Telephone: / adeltsidou@teiath.gr Ó 2011 Blackwell Publishing Ltd, Journal of Clinical Nursing, 20, doi: /j x

2 K Lykeridou et al. Introduction Infertility, the inability of a woman to become pregnant after one year of regular sexual intercourse without contraceptives, is perceived as a problem across almost all cultures and societies. Clinicians and researchers consistently report that infertile women view infertility and its treatment as extremely stressful (Chen et al. 2004, Dyer et al. 2005, Ozkan & Baysal 2006, Wang et al. 2007). Individual differences in psychological stress suggest that various psychological processes mediate or moderate the relationship between stressors and the psychological reaction to a chronic disease (Lazarus & Folkman 1984). It is, therefore, extremely important to understand both the magnitude of stress and the personal coping resources of infertile women, as they try to deal with the problems associated with infertility and its treatment. A range of demographic and psychosocial variables may influence the stress associated with infertility treatment. Variables such as coping skills and social class may be considered determinants of emotional stress and may be also considered as either risk or protective factors to explain individual differences in emotional stress attributed to infertility. Coping refers to cognitive and behavioural efforts to master, reduce, or tolerate the internal and/or external demands created by the stressful transaction (Lazarus & Folkman 1984). This does not necessarily succeed in eliminating the stressor, but it may manage the stressor through various means, for example by coming up with new ways to deal with it, reappraising it or minimising it, learning to tolerate it and accepting it (Morrison & Bennett 2006). Coping has two widely recognised major functions: regulating stressful emotions (emotion-focused coping strategies such as passive and active avoidance, escaping, seeking social support and positively reappraising the stressor) and managing the problem that is causing the distress (problem-focused coping strategies such as planning how to change the stressor, seeking practical or informational support and confronting the stressful situation) (Lazarus & Folkman 1984, Carver et al. 1989). Problem-focused forms of coping are usually used in situations that are appraised as changeable, thereby holding the potential of control and emotion-focused forms of coping are usually used in situations that are appraised as not amenable to change and uncontrollable (Folkman 1984). The effectiveness of emotion-focused coping and problemfocused coping strategies has been studied in the coping literature. In a large number of cross-sectional and longitudinal studies, problem-focused strategies have been found to be associated with better adjustment, (e.g. Dunkel-Schetter et al. 1992, Terry et al. 1995), whereas emotion-focused strategies have been associated with poor adjustment (Carver et al. 1993, Terry et al. 1995). Typically, the positive relationship between problem-focused coping and better adjustment is attributed to the fact that problem-focused coping engages the individual to focus his/her attention on specific goals, makes him/her feel effective and allows him/her to experience situational mastery and control, whereas the negative impact of emotion-focused strategies is attributed to the failure of such efforts to confront the event (Lazarus & Folkman 1984, Folkman & Moskowitz 2000). However, in response to low-control stressful situations, specific problemfocused coping strategies, such as problem-management coping, are likely to have deleterious effects presumably because such efforts engender feelings of frustration and disappointment (Terry & Hynes 1998). Interestingly, some emotion-focused coping strategies (e.g. seeking social support, positive reappraisal, meaning-based coping) are effective in reducing distress, whereas others (e.g. escaping and distancing) promote increases in distress. For example, an individual who uses distancing and escape-avoidance coping strategies when he/she should instead face the problem he/she may experience increased distress (Folkman et al. 1986, Valentiner et al. 1994). On the other hand, positive reappraisal, finding a positive meaning and seeking social support, which are also forms of emotion-focused coping, have been shown to decrease distress (Folkman & Moskowitz 2000). Therefore, certain problem-focused coping strategies may be adaptive in controllable situations, while certain emotionfocused coping may be adaptive in uncontrollable situations. Folkman and Lazarus (1980) have shown that both types of coping strategies are used in most of the stressful situations individuals encounter and that the relative proportions of each type vary according to factors, such as, the appraised characteristics of the stressful condition (controllability), personality dispositions and social resources (Folkman & Moskowitz 2000). Social class refers to the economical or cultural, hierarchical arrangement of people in society. In social sciences, social class is often discussed in terms of social stratification. According to Boivin et al. (2006), low social class, which may be equivalent to low resources, is likely to be associated with greater infertility-related stress. According to Waser and Isenberg (1986), reproductive suppression should vary according to the economic and social resources available to the individual because humans as a species are social and these resources are fundamental tools in the defence against stressful life events. Individuals with more resources have stronger defences and are better able to withstand the effects of stress than those with fewer resources. Kristenson et al. (2004) found that sustained stress hormone activation (e.g. higher cortisol levels) and altered responsivity to stressful 1972 Ó 2011 Blackwell Publishing Ltd, Journal of Clinical Nursing, 20,

3 Patient experiences situations are more common in people from low socioeconomic backgrounds. Thus, it could be hypothesised that women of lower social class would experience a higher level of infertility-related stress because they lack environmental buffers against psychosocial stress. Background Several studies have been conducted to examine the impact of coping on infertility-related stress. Studies among women or couples in in vitro fertilisation (IVF) treatment (Berghuis & Stanton 2002, Mindes et al. 2003, Peterson et al. 2006, Lechner et al. 2007) have shown that avoidance or escape coping was a predictor of a high level of infertility-related distress, whereas problem-focused coping and meaning-based (finding a positive meaning) coping were predictors of a better adjustment. However, Verhaak et al. (2005a,b) suggested that coping factors do not determine the psychological stress following an unsuccessful treatment; in their subsequent study (2005b), they reported that there was no relationship between problem-focused, active coping and changes in anxiety and depression after a failed infertility treatment. A few studies have focused on the relationship between social status and coping strategies (Thoits 1995, Taylor & Seeman 1999, Schmidt et al. 2005a). Taylor and Seeman (1999) found that, when socio-economic status decreased, avoidant coping was more prevalent. Ross and Mirowsky (1989) found that highly educated people were more likely to use active problem solving, and Grossi (1999) also reported that problem-focused coping was less frequent among participants with a low education coupled with low financial strain. In addition, findings of the study conducted by Donkor and Sandall (2007) suggested that infertile women of low occupational social class experienced a higher level of infertilityrelated stress while women of high occupational social class experienced the least infertility-related stress. Possibly, individuals of higher social classes are more likely to use approach coping and less likely to use avoidance coping. Therefore, it could be hypothesised that higher social class is associated with psychological adjustment indirectly through the coping strategies that individuals use under stress. However, Schmidt et al. (2005a) showed that infertile women from lower social classes used significantly more active-confronting coping and meaning-based coping and women from higher social classes used significantly more avoidance coping. Aim The aims of this cross-sectional study were to examine the association between (1) coping responses and occupational social class, (2) coping responses and infertility-related stress and (3) occupational social class and infertility-related stress. On the basis of a previous research study, we hypothesised that people of higher social classes would use more active problem-solving strategies and less avoidant coping strategies and that they would experience a lower level of infertilityrelated distress when compared with the people of lower social class. We also hypothesised that the greater use of avoidance coping and lesser use of active coping would be associated with higher infertility-related stress. Methods Study setting The study was conducted in one of the largest public infertility clinics in Greece to achieve a large and representative sample. While the clinic is located in Athens, infertile women come to this clinic, not only from the capital of Greece, but also from rural areas of Greece. The financial costs of infertility treatments provided by public IVF clinics are covered by the Greek National Health System. The staff of this clinic includes obstetricians, midwives, nurses, laboratory personnel and secretaries. There are no psychologists, social workers or sex therapists employed at the public IVF clinics since psychological counselling regarding infertility, and its treatment is not mandatory in Greek public infertility clinics. Study design and data collection This study was a cross-sectional survey that involved collecting information from the participants by using two questionnaires. All the women received a letter in an envelope just before undergoing their first treatment attempt in that clinic. A member of the research team approached each woman who expressed interest in participating in the study, while the aim and expected benefits of the study were explained in a letter to provide further information about the study. The researcher provided explanations to the participants when necessary; thereafter, the questionnaires were returned to the researcher, who was not an employee of the fertility clinic. Participants Coping with infertility and social class The sample consisted of infertile women undergoing infertility treatment. According to the inclusion criteria, the women chosen (1) were able to read and write in the Greek language to ensure the ability to complete the questionnaires, (2) had Ó 2011 Blackwell Publishing Ltd, Journal of Clinical Nursing, 20,

4 K Lykeridou et al. unsuccessfully tried to conceive a child with natural methods for more than one year and (3) had received an infertility diagnosis and were not waiting for a new one. Researchers approached 452 women in the infertility clinic asking them to participate in the study; 410 women (90Æ7%) agreed to take part in the study; finally, 404 women (89Æ3%) returned completed questionnaires. The mean age of participants was [36Æ9 (4Æ1) years, range = 25 47], and the majority of them had a medium educational level, had no children and participated in the workforce, as described in Table 1. Measures To assess the psychological disturbances quantitatively, validated and standardised psychometric tools were used. The research instruments were two self-administrated questionnaires. The State-Trait Anxiety Inventory questionnaire (STAI) (Spielberger 1972) and the Copenhagen Multi-centre Psychosocial Infertility (COMPI) questionnaire (Schmidt et al. 2003a) were employed to assess the participants infertility-related stress on the personal, marital and social domain as well as their coping strategies and social class. Table 1 Sociodemographic, medical and treatment characteristics of the participants Participants characteristics Participants (n = 404) % Sociodemographic characteristics Age (years) 30 6Æ Æ Æ0 Occupational social class High 49Æ0 Medium 27Æ0 Low 13Æ0 Outside classification 11Æ0 Educational level High (tertiary) 38Æ0 Medium (secondary) 48Æ0 Low (primary) 14Æ0 Medical characteristics Diagnosed female infertility 25Æ0 Diagnosed male infertility 37Æ0 Diagnosed mixed infertility 22Æ0 Unknown factor infertility 16Æ0 Child existence Yes 22 No 376 No. of previous treatments, mean (SD) Duration of infertility, mean (SD) Mean (SD) 2Æ4 (2Æ0) 2Æ1 (0Æ9) The STAI questionnaire was used to measure state and trait anxiety in women undergoing infertility treatment. The STAI state scale consists of 20 items that ask respondents to describe how they feel at a particular moment in time and the STAI trait scale consists of 20 items that ask respondents to describe how they generally feel (e.g. confident). Responses are rated on a four-point Likert scale. Total scores for state and trait anxiety range from (McDowell 2006), whereas the published normative state and trait anxiety scores of non-pregnant women are 35Æ2 (10Æ6) and 34Æ8 (9Æ2), respectively. Total scores for people diagnosed with anxiety disorder range between (McDowell 2006). The STAI has been adapted to Greek and has been found to have satisfactory psychometric properties (state a =0Æ92, trait a = 0Æ89) and construct validity (Liakos & Gianitsi 1984). The COMPI questionnaire has been adapted from a previous Danish study (Schmidt et al. 2003a, Schmidt 2006). Details about the development of this measure are available in other studies (Schmidt et al. 2003a,b). However, some information about the COMPI questionnaire is also presented in this article. A total number of 14 items from the COMPI questionnaire were used to assess the sociodemographic profile of the participants. The sociodemographic background information included variables concerning age, years of marriage, occupational social position and educational level. Education was categorised into three levels: low, medium and high. Low educational level referred to primary education, medium educational level referred to secondary education and high educational level referred to a university/polytechnic school degree or higher. A measure of occupational social position was used. Based on this measure, social position was recoded into three levels: from social class I (high level) to social class III (low level). High level included professionals and executives; medium level included whitecollar employees and skilled workers; low level included all unskilled workers and participants supported by the Social Benefit Program. Medical background information included information regarding duration of infertility, former children, diagnosis of infertility and past infertility treatment. A total of 16 items from the COMPI questionnaire were used to measure infertility-related stress. Infertility-related stress was measured by using three subscales referring to the personal, social and marital domain. These subscales are described in detail by Schmidt et al. (2003a). Infertilityrelated stress in the personal domain (six items, range 0 20) reflected the stress that infertility had produced on the person s physical and mental health. Infertility-related stress in the social domain (four items, range 0 12) assessed the extent to which infertility had caused strain on social 1974 Ó 2011 Blackwell Publishing Ltd, Journal of Clinical Nursing, 20,

5 Patient experiences Coping with infertility and social class relations with friends, family and colleagues. Infertilityrelated stress in the marital domain (four items, range 0 14) assessed the stress that infertility had produced on marital and sexual relations. The response categories from the subscales of personal stress, social stress and two items from marital stress were rated on a four-point Likert response scale from (1) none at all (4) a great deal. For the remaining two items of marital stress, a five-point Likert scale from (1) strongly disagree (5) strongly agree was used. Total scores were calculated by summing the relevant items. Higher scores indicated higher personal, social and marital stress. The items related to coping consisted of four subscales based on their conceptual content: (1) active-avoidance strategies (e.g. avoiding pregnant women or children) (four items, range 4 16), (2) active-confronting strategies (e.g. showing feelings, asking others for advice and information) (seven items, range 7 26), (3) passive-avoidance strategies (e.g. hoping for a miracle) (three items, range 3 12) and (4) meaning-based coping (e.g. growing as a person in a good way, finding other goals in life) (five items, range 5 20). The response key was (1) not used, (2) used somewhat, (3) used quite a bit and (4) used a great deal. The subscales integrated items that were significantly intercorrelated (Schmidt et al. 2005b). The reliability of the COMPI subscales was assessed by Cronbach s alpha. In this study, the alpha coefficient for the personal stress subscale, the social stress subscale and the marital stress subscale ranged from 0Æ80 0Æ85, while the alpha coefficient for the active-avoidance coping scale, the active-confronting coping scale, the passive-avoidance coping scale and the meaning-based coping scale ranged from 0Æ80 0Æ85. These values were within the acceptable limits (Carter & Porter 2004). In this study, the alpha coefficient of the STAI was 0Æ87 for state and 0Æ83 for trait anxiety. Translation and questionnaire pilot The questionnaires were translated from English into Greek by two independent bilingual persons and then back-translated into English by two other bilingual individuals. Then, the questionnaires were piloted using cognitive interviewing methods with the objective of examining the understanding of the questions to eliminate any ambiguities in the questions and predict the completion time. The sample of the cognitive testing consisted of 40 women with different demographic characteristics to ensure the representation of the main sample. During the cognitive interviews, each respondent was asked to follow the procedure as closely as possible to the real procedure; this involved reading the information letter and completing the questionnaire. While the participants were completing the questionnaire, the researcher sat opposite them and observed any hesitations. The respondents provided feedback to the researcher by thinking aloud during the completion of the questionnaire. The returned questionnaires were fully completed, and the response choices were adequate and understandable. Ethical considerations Permission to complete this study was obtained from an institutional ethical research committee. Participants were assured of the anonymity and confidentiality of their answers and informed of their right to refuse to go on with the survey at any time. Participants were also assured that the data would be used only for this study and that their decision to withdraw or refuse to participate would not compromise the standard of the received care. It was assumed that completing the questionnaire equated consent. Non-return of questionnaires was taken to indicate a desire not to participate in the study. Data analysis Descriptive and inferential statistics were performed using SPSS version 18.0 (PASW/SPSS Inc., Chicago, IL, USA). Data analyses involved descriptive statistics to calculate frequencies and means for each variable and to make crosstabulations between variables. Analysis of variance (ANOVA) was carried out when comparing multiple groups of data. Specifically, levels of anxiety and infertility-related stress were compared and associated with the social groups by using a one-way ANOVA. Post hoc analysis of significant ANOVA comparisons using the Bonferroni test were performed to determine the social class groups that demonstrated significant differences and had the highest level of infertility-related personal, marital, social stress, state anxiety and trait anxiety. Moreover, bivariate correlations between coping and stress subscales were performed using the Pearson s correlation coefficient. Results are expressed as values of F-statistics as well as p-values. The statistical significance level was set at 0Æ05. Results Demographic features and medical characteristics of the sample are shown in Table 1. The mean age was 36Æ9 years. The mean duration of infertility was reported to be 5Æ17 (SD 3Æ9) years. Most women (95%) reported having no children and only 5% of women had at least one child. Ó 2011 Blackwell Publishing Ltd, Journal of Clinical Nursing, 20,

6 K Lykeridou et al. The mean score of participants state anxiety was 44Æ5 (SD 9Æ5) and trait anxiety was 41Æ8 (SD 7Æ1). Both scores were found to be much higher than the published normative scores of state and trait anxiety, which are 35Æ2 and 34Æ8, respectively (McDowell 2006). Taking into consideration the ranges for the low and high level in each subscale of infertility-related stress (Schmidt et al. 2005a), the findings of this study showed low levels of experienced infertilityrelated stress [12Æ91 (SD 7Æ4)] with subscales of personal (range 0 20, mean 7Æ95), social (range 0 12, mean 1Æ9) and marital stress (range 0 14, mean 3Æ1). The mean score of participants active-avoidance coping was 7Æ3 (SD 2Æ7), of active confronting was 12Æ01 (SD 2Æ9), of passive-avoidance strategies was 7Æ99 (SD 2Æ4) and of meaning-based coping was 13Æ93 (SD 3Æ2). The relationship between the women s coping strategies and their demographic characteristics was explored. Women below 35-year old scored significantly higher in the activeavoidance coping scale [1Æ63 (SD 2Æ51)], comparison with those older than 35 years [1Æ04 (SD 2Æ74)]. Women who already had a child scored significantly lower in the same scale [6Æ4 (SD 1Æ90) vs. 7Æ37 (SD 2Æ71)]. No differences were observed concerning the coping strategies between rural and urban women. As for anxiety and stress levels, women of low social class presented higher scores in the state anxiety scale (STAI) when compared with women of medium and higher social class [49Æ43 (SD 10Æ15) vs. 43Æ55 (SD 9Æ35) and 42Æ54 (SD 8Æ95), respectively, p < 0Æ001] (Table 2). The results also revealed that women s level of social class influenced their perceived personal stress (p =0Æ014) and the trait anxiety level (p = 0Æ001). Post hoc comparisons revealed that participants of low/very low social class reported higher levels of personal stress (F =4Æ346, p =0Æ014), trait anxiety (F =7Æ236, p =0Æ001) and state anxiety (F =9Æ796, p < 0Æ001) than those of medium or high social class. No differences were observed concerning social, marital and total stress (Table 2). Post hoc analyses also revealed that women of low/very low social class reported higher levels of active-confronting coping than women of medium or high social class (F =7Æ997, p < 0Æ001). It has been also found that women of low/very low social class reported higher levels of passiveavoidance coping than women of medium or high social class. However, this difference was marginally statistically significant (p = 0Æ051). For the other two coping subscales, no difference was observed in the women s responses between the different social classes (Table 2). A positive correlation was observed between activeavoidance coping and both state and trait anxiety (r = 0Æ278, r =0Æ233, respectively, p < 0Æ001). The meaningbased scale was negatively correlated with state anxiety (r = 0Æ201) (Table 3) as well as marital stress and social stress (r = 0Æ234, p < 0Æ001, r = 0Æ122, respectively, p < 0Æ05). Passive-avoidance coping was positively correlated with marital stress and personal stress (r = 0Æ186, r = 0Æ146, respectively, p < 0Æ001). All three kinds of stress (marital, personal and social) were positively correlated both with active-avoidance (r =0Æ302, r =0Æ423, r =0Æ211, respectively, p < 0Æ001) and slightly positively correlated with the active-confronting scale (r = 0Æ150, r = 0Æ211, r = 0Æ141, respectively, p < 0Æ001) (Table 3). Discussion We anticipated that individuals of higher social classes would use a more extensive coping range and that they would adopt more active problem-solving coping approaches. According to Poetz et al. (2007), low social class is positively related to maladaptive coping strategies through multiple variables, such as low educational level and low income. In highly Table 2 Comparison of mean values of women s responses regarding the perceived infertility-related stress by social class High social class A Medium social class B Low and very low social class C F* p* Post hoc Stress subscales Marital stress 2Æ98 (2Æ5) 3Æ08 (3Æ1) 2Æ74 (2Æ1) 0Æ420 0Æ657 Social stress 1Æ82 (2Æ1) 1Æ78 (2Æ0) 1Æ98 (2Æ2) 0Æ239 0Æ787 Personal stress 7Æ36 (4Æ0) 7Æ8 (3Æ8) 8Æ85 (4Æ0) 4Æ346 0Æ014 C > A, B Anxiety scales State anxiety 43Æ55 (9Æ3) 42Æ54 (8Æ9) 49Æ43 (10Æ1) 9Æ796 0Æ000 C > A, B Trait anxiety 41Æ59 (7Æ3) 40Æ30 (6Æ5) 43Æ87 (7Æ3) 7Æ236 0Æ001 C > A, B Coping subscales Active-confronting coping scale 11Æ74 (3Æ0) 11Æ62 (2Æ4) 13Æ18 (2Æ8) 7Æ997 0Æ000 C > A, B Active-avoidance coping scale 7Æ16 (2Æ4) 7Æ31 (2Æ8) 7Æ23 (2Æ7) 0Æ107 0Æ898 Meaning-based coping scale 13Æ91 (3Æ0) 13Æ83 (3Æ3) 14Æ62 (2Æ9) 1Æ690 0Æ186 Passive-avoidance coping scale 7Æ82 (2Æ5) 7Æ82 (2Æ4) 8Æ59 (1Æ7) 3Æ149 0Æ051 *F and p-value obtained with ANOVA. Significant post hoc comparisons (alpha level <0Æ05) with Bonferroni test Ó 2011 Blackwell Publishing Ltd, Journal of Clinical Nursing, 20,

7 Patient experiences Coping with infertility and social class Table 3 Correlations of coping strategies and anxiety and stress scales Coping strategies Marital stress Social stress Personal stress State anxiety Trait anxiety Active-confronting coping scale 0Æ150* 0Æ211* 0Æ141* 0Æ278* 0Æ233* Active-avoidance coping scale 0Æ302* 0Æ423* 0Æ211* 0Æ041 0Æ037 Passive-avoidance coping scale 0Æ186* 0Æ052 0Æ146* 0Æ089 0Æ081 Meaning-based coping scale 0Æ234* 0Æ122 0Æ055 0Æ201* 0Æ096 *p < 0Æ001, p < 0Æ05, correlation coefficient is reported. educated people, relatively high levels of intellectual function are related to positive health-related behaviours and can result in assuming more adaptive coping styles (Roohafza et al. 2009). According to the findings of previous investigators, highly educated individuals are more prone to use problem-focused approaches, such as doing something regarding a problem, outlining the cause, thinking through the situation and looking for information (Ross & Mirowsky 1989, Grossi 1999, Roohafza et al. 2009). Contradictory to this, we revealed that women of the lower social classes showed significantly more active-confronting coping in comparison with women of the higher social classes. Our findings are in line with the findings of Schmidt et al. (2005a) who observed that people of higher social classes used significantly less active-confronting coping. Schmidt et al. (2005a) attributed their finding to the fact that the scale used to measure active-confronting coping included items concerning seeking infertility-associated information. Based on the foregoing, they posited that individuals of higher social classes had a lower score of active-confronting coping because they likely were more informed before starting infertility treatment. We also projected that individuals of lower social classes would demonstrate more maladaptive (active and passiveavoidance coping) coping strategies. We measured avoidance coping with two diverse subscales as described above: activeavoidance (e.g. avoid being with pregnant women or children) and passive-avoidance (e.g. making wishes, having fantasies and waiting for a miracle). Women of lower social classes demonstrated significantly higher levels of passiveavoidance coping strategies than individuals of higher social classes. This is in accordance with findings by Schmidt et al. (2005a) and it could be attributed to the fact that women of lower social classes may have lower self-confidence and higher fatalism than women of higher social and educational levels (Caplan & Schooler 2007). On the other hand, no significant difference was observed between women from different social classes regarding the use of active-avoidance coping strategies. This is in accordance with the findings of Christensen et al. (2006) who found that there was no correlation between avoidance coping and social class and in contrast with the findings of Schmidt et al. (2005a) who found that women of lower social classes used activeavoidance coping strategies less frequently than individuals of higher social classes. Moreover, a positive correlation between all the types of stress (personal, marital and social) and the active-avoidance coping strategy was found. In addition, the state and trait anxiety of infertile women was positively associated with active-avoidance. Our findings are in line with findings of previous studies (Schmidt et al. 2005a, Peterson et al. 2006, 2008) and can be explained by the fact that individuals with high stress levels seek any way possible to relieve stress and its consequences, even using a maladaptive coping strategy (e.g. keep away themselves from coexistence with people having children) (Roohafza et al. 2009). Strengths The study has several strengths: (1) the questionnaires used in this study have been previously evaluated and have been proven to be reliable and valid measures, (2) the response rate was satisfactory (89Æ3%) ensuring a large sample size (n = 404) and (3) all items of the questionnaires were answered by almost all of the participants. These strengths ensure the reliability of the study findings. Limitations The study had two main limitations. First, the study sample comprised participants who had decided to seek assisted reproductive treatment. We were thus unable to observe coping processes and their social gradient among infertile people not seeking assisted reproductive treatment. The second limitation of this study was that the sample was drawn from one public infertility clinic rather than from many clinics, which may decrease the generalisability of study findings. Conclusions In conclusion, we found, contrary to our expectations, that among infertile participants in assisted reproductive treatment, infertile women of the lowest social classes used more active-confronting coping and more passive-avoidance Ó 2011 Blackwell Publishing Ltd, Journal of Clinical Nursing, 20,

8 K Lykeridou et al. coping than women of the highest social classes. Thus, the study suggests that elements of coping may be learned from one s social network and that certain factors might make particular infertile individuals more vulnerable to infertilityrelated stress and anxiety. Low social class and maladaptive coping strategies, such as active and passive-avoidance coping, could be considered as risk factors for distress in infertile individuals undergoing infertility treatment. infertility. To subordinate the threshold for attending infertility counselling and to eliminate discrimination, printed information or video presentations concerning psychosocial responses to infertility and coping with this situation must be offered to couples at the beginning of infertility treatment. We also recommend that counselling by specially trained staff should be provided at all stages of infertility management and even if treatment fails. Relevance to clinical practice By assessing these factors, medical professionals, specifically nurses and midwives who work in infertility clinics, may be able to identify individuals who are at greater risk for infertility distress and adjustment difficulties. The specially trained nurses and midwives should initially assess the psychological status and specifically the distress levels of infertility patients. Furthermore, the goal of their interventions should be the minimisation of identified risk factors for infertility-related distress and the strengthening of protective factors. Thus, professionals should discourage avoidance and promote active problem solving and positive reappraisal of Acknowledgement The Project was co-funded by the European Union European Social Fund and National Resources (EPEAEK-II). Contributions Study design: KL, KG, AD; data collection and analysis: AS, DL and manuscript preparation: KL, KG, AD, GV. Conflict of interest None. References Berghuis JP & Stanton AL (2002) Adjustment to a dyadic stressor: a longitudinal study of coping and depressive symptoms in infertile couples over an insemination attempt. Journal of Consulting and Clinical Psychology 70, Boivin J, Sanders K & Schmidt L (2006) Age and social position moderate the effect of stress on fertility. Evolution and Human Behavior 27, Caplan L & Schooler C (2007) Socioeconomic status and financial coping strategies: the mediating role of perceived control. Social Psychological Quality 70, Carter D & Porter S (2004) Validity and reliability. In The Research Process in Nursing (Cormack D ed.). Blackwell Science, Oxford, pp Carver C, Scheier M & Weintraub JK (1989) Assessing coping strategies: a theoretically based approach. Journal of Personality and Social Psychology 56, Carver C, Pozo C, Harris S, Noriega V, Scheier M, Robinson D, Ketcham S, Moffat E & Clark K (1993) How coping mediates the effects of optimism on distress: a study of women with early stage breast cancer. Journal of Personality and Social Psychology 65, Chen TH, Chang SP, Tsai CF & Juang KD (2004) Prevalence of depressive and anxiety disorders in an assisted reproductive technique clinic. Human Reproduction 19, Christensen U, Schmidt L, Hougaard C, Kriegbaum M & Holstein B (2006) Socioeconomic position and variations in coping strategies in musculoskeletal pain: a cross sectional study of and 50-year-old men and women. Journal of Rehabilitation Medicine 38, Donkor E & Sandall J (2007) The impact of perceived stigma and mediating social factors on infertility-related stress among women seeking infertility treatment in Southern Ghana. Social Sciences and Medicine 6, Dunkel-Schetter C, Feinstein LG, Taylor SE & Falke RL (1992) Patterns of coping with cancer. Health Psychology 11, Dyer J, Abrahams N, Mokoena N, Lombard C & van der Spuy Z (2005) Psychological distress among women suffering from couple infertility in South Africa: a quantitative assessment. Human Reproduction 20, Folkman S (1984) Personal control and stress and coping process: a theoretical analysis. Journal of Personality and Social Psychology 46, Folkman S & Lazarus R (1980) An analysis of coping in middle-aged community sample. Journal of Health and Social Psychology 46, Folkman S & Moskowitz T (2000) Positive affect and the other side of coping. American Psychologist 55, Folkman S, Lazarus R, Dunkel-Schetter C, Delongis A & Gruen R (1986) Dynamics of a stressful encounter: cognitive appraisal, coping and encounter outcomes. Journal of Personality and Social Psychology 50, Grossi G (1999) Coping and emotional distress in a sample of Swedish unemployed. Scandinavian Journal of Psychology 40, Kristenson M, Eriksen H, Sluiter J, Starke D & Ursin H (2004) Psychobiological mechanisms of socioeconomic differ Ó 2011 Blackwell Publishing Ltd, Journal of Clinical Nursing, 20,

9 Patient experiences Coping with infertility and social class ences in health. Social Sciences and Medicine 58, Lazarus RS & Folkman S (1984) Stress, Appraisal and Coping. Springer, New York. Lechner L, Bolman C & Van Dalen A (2007) Definite involuntary childlessness: associations between coping, social support and psychological distress. Human Reproduction 22, Liakos A & Gianitsi S (1984) The validity and reliability of the revised Greek anxiety scale by Spielberger. Engefalos 21, McDowell I (ed.) (2006) Measuring Health. A Guide to Rating Scales and Questionnaires, 3rd edn. Oxford University Press, Oxford. pp Mindes E, Ingrama K, Kliewera W & James C (2003) Longitudinal analyses of the relationship between unsupportive social interactions and psychological adjustment among women with fertility problems. Social Science and Medicine 56, Morrison V & Bennett P (2006) Stress and illness moderators. In An Introduction to Health Psychology (Morrison V & Bennett P eds). Pearson Education Limited, London, pp Ozkan M & Baysal B (2006) Emotional distress of infertile women in Turkey. Clinical & Expimental Obstetrics & Gynaecology 33, Peterson B, Newton C, Rosen K & Skaggs G (2006) The relationship between coping and depression in men and women referred for in vitro fertilization. Fertility Sterility 85, Peterson B, Pirritano M, Christensen U & Schmidt L (2008) The impact of partner coping in couples experiencing infertility. Human Reproduction 23, Poetz A, Eyles J, Elliot S, Wilson K & Keller-Olaman S (2007) Path analysis of income, coping and health at the local level in a Canadian context. Health Social Care Community 15, Roohafza H, Sadeghi M, Shirani S, Bahonar A, Mackie M & Sarafzadegan N (2009) Association of socioeconomic status and life-style factors with coping strategies. Croatian Medical Journal 50, Ross CE & Mirowsky J (1989) Explaining the social patterns of depression: control and problem solving or support and talking? Journal of Health and Social Behavior 30, Schmidt L (2006) Infertility and assisted reproduction in Denmark. Epidemiology and psychosocial consequences. Danish Medical Bulletin 53, Schmidt L, Holstein B, Boivin J, Sångren H, Tjørnhøj-Thomsen T, Blaabjerg J, Hald F, Andersen AN & Rasmussen PE (2003a) Patients attitudes to medical and psychosocial aspects of care in fertility clinics: findings from the Copenhagen Multi-centre Psychosocial Infertility (COMPI) Research Programme. Human Reproduction 18, Schmidt L, Holstein B, Boivin J, Sångren H, Tjørnhøj-Thomsen T, Blaabjerg J, Hald F & Andersen AN (2003b) High ratings of satisfaction with fertility treatment are common: findings from the Copenhagen Multi-centre Psychosocial Infertility (COMPI) Research Programme. Human Reproduction 18, Schmidt L, Christensen U & Holstein BE (2005a) The social epidemiology of coping with infertility. Human Reproduction 20, Schmidt L, Holstein B, Christensen U & Boivin J (2005b) Communication and coping as predictors of fertility problem stress: cohort of 816 participants who did not achieve a delivery after 12 months of fertility treatment. Human Reproduction 20, Spielberger C (1972) Anxiety: Current Trends in Research. Academic Press, London. Taylor SE & Seeman TE (1999) Psychosocial resources and the SES-health relationship. In Socioeconomic Status and Health in Industrialised Nations (Adler NE, Marmot M, McEwen BS & Stewart J eds). New York Academy of Sciences, New York, USA, pp Terry D & Hynes G (1998) Adjustment to a low- control situation: reexamining the role of coping responses. Journal of Personality and Social Psychology 74, Terry DJ, Tonge L & Callan VJ (1995) Employee adjustment to stress: the role of coping resources, situational factors and coping responses. Anxiety, Stress and Coping 8, Thoits P (1995) Stress, coping and social support processes: where we are? What next? Journal of Health and Social Behavioral (Extra Issue), Valentiner D, Holahan C & Moos R (1994) Social support, appraisals of event controllability and coping: an integrative model. Journal of Personality and Social Psychology 66, Verhaak CM, Smeenk JM, Evers AW, van Minnen A, Kremer JA & Kraaimaat FW (2005a) Predicting emotional response to unsuccessful fertility treatment: a prospective study. Journal of Behavioral Medicine 2, Verhaak CM, Smeenk JM, van Minnen A, Kremer JA & Kraaimaat FW (2005b) A longitudinal, prospective study on emotional adjustment before, during and after consecutive fertility treatment cycles. Human Reproduction 20, Wang K, Li J, Zhang J, Zhang L, Yu J & Jiang P (2007) Psychological characteristics and marital quality of infertile women registered for in vitro fertilization intracytoplasmatic sperm injection in China. Fertility Sterility 87, Waser S & Isenberg D (1986) Reproductive failure among women: pathology or adaptation? Journal of Psychosomatic Obstetrics Gynecology 5, Ó 2011 Blackwell Publishing Ltd, Journal of Clinical Nursing, 20,

10 K Lykeridou et al. The Journal of Clinical Nursing (JCN) is an international, peer reviewed journal that aims to promote a high standard of clinically related scholarship which supports the practice and discipline of nursing. For further information and full author guidelines, please visit JCN on the Wiley Online Library website: wileyonlinelibrary.com/journal/jocn Reasons to submit your paper to JCN: High-impact forum: one of the world s most cited nursing journals and with an impact factor of 1Æ194 ranked 16 of 70 within Thomson Reuters Journal Citation Report (Social Science Nursing) in One of the most read nursing journals in the world: over 1 million articles downloaded online per year and accessible in over 7000 libraries worldwide (including over 4000 in developing countries with free or low cost access). Fast and easy online submission: online submission at Early View: rapid online publication (with doi for referencing) for accepted articles in final form, and fully citable. Positive publishing experience: rapid double-blind peer review with constructive feedback. Online Open: the option to make your article freely and openly accessible to non-subscribers upon publication in Wiley Online Library, as well as the option to deposit the article in your preferred archive Ó 2011 Blackwell Publishing Ltd, Journal of Clinical Nursing, 20,

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